December 18, 2019By Dr. Kim Baily

US State Nursing Simulation Regulations for Prelicensure Nursing Programs

The much quoted 2014 NCSBN National Simulation Study suggests that simulation can replace up to 50% of traditional clinical time without any effect on clinical competency, comprehensive nursing knowledge assessments, NCLEX pass rates or overall clinical competency after six months of post licensure practice. However, the report does specify that this equivalency is only valid when the simulation program is considered to be “high quality”. Here, Dr. Kim Baily, PhD, MSN, RN, CNE considers the use of nursing simulation in prelicensure nursing programs has increased significantly in the last decade.

When clinical places or qualified faculty are scarce, some schools have seized on this study to increase the use of medical simulation without due consideration as to whether or not their school offers “high quality” clinical simulation.

Although national simulation organizations such as the International Nursing Association for Clinical Simulation and Learning (INACSL), National League for Nursing (NLN) and the Society for Simulation in Healthcare (SSH) have worked hard to create voluntary standards and accreditation criteria, ultimately the responsibility for ensuring adequate pre-licensure simulation education belongs with the Boards of Nursing (BONs) of each state.


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According to the US constitution, all forms of licensure are governed by a state-based regulatory systems. Boards of Nursing are unique regulatory agencies responsible for ensuring public safety by enacting a state Nurse Practice Act which includes regulations for initial approval and ongoing regulation of nursing education programs. The Nurse Practice Acts, which are different for each state, include regulations for clinical hours, faculty preparation, student to faculty ratios and types of clinical experiences.

A recent study by Bradley et al. investigated current state regulations in the United States for prelicensure nursing programs. (Bradley, C. S., Johnson, B. K., Dreifuerst, K. T., White, P., Conde, S. K., Meakim, C. H., Curry-Lourenco, K., & Childress, R. M. (2019, August). Regulation of simulation use in united states prelicensure nursing programs. Clinical Simulation in Nursing, 33(C). The study surveyed all state Boards of Nursing and the District of Columbia by phone, mail and email. The survey found marked differences not only in the way the BONs defined simulation but also in the type and extent of regulations related to simulation. Only data that was documented and publicly accessible were collected and compiled into an excel spreadsheet using the exact BON wording to preserve data integrity. No anecdotal reports or survey data were collected.

Considering the Regulations

Of the 50 states plus DC, 30 BONs had documented regulations for the use of healthcare simulation in a nursing program, whereas 21 BONs had no simulation regulations that could be located or officially verified.


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Definition of Nursing Simulation

Of the 30 BON with simulation regulations, 23 defined simulation while 7 (AL, CA, FL, IL, KY, SD, and VA) had no definitions which is rather odd since defining simulation regulations without a clear description of what constitutes simulation must lead to variation in simulation practice within the 7 states.

Clinical Hour Replacement with Simulated Nursing

Twenty-five BONs defined the percentage of clinical hours that could be replaced with simulation. Thirteen BONs allow up to 50% (FL, IA, KY, LA, MN, NH, NM, SC, SD, TN, TX, WA, and WI). Other states allow smaller percentages – 30% replacement (DC and OK), and 25% replacement (CA, IL, IN, MS, NV, VT, and VA). Four BONs with regulations did not specify (AL, GA, MO, and RI). Interestingly, some states vary the replacement depending on whether the simulation program is accredited. For example. Colorado allows up to 50% replacement of traditional clinical hours with simulation if the program is accredited but only 25% if the program is not. Some states have variations depending on the area of practice. For example, Ohio allows up to 50% replacement with mid- or high-fidelity simulation in pediatrics and obstetrics only and Michigan allows no more than 50% replacement for RN programs but allows up to 100% replacement with simulation in practical nursing programs for pediatrics and obstetrics courses only. This might be due to a lack of available placements.

Healthcare Simulation Hours Substituted for Traditional Clinical Hours

Current nursing education research is attempting to determine the equivalency in hours between traditional clinical hours versus simulation hours. Some authorities believe the ratio is one to one while newer research indicates that two hours of clinical experience may be equivalent to one of simulation. In the Bradley et al. survey, of the 30 states with regulations, 25 did not define equivalency, 3 counted clinical and simulation equal and one state (CO) counted 2 hours of clinical as equivalent to 1 hour of simulation if the program was nationally accredited but only 1:1 if the program was not accredited.

Until research studies clearly identify the relationship between the learning that goes on in clinical hours versus the learning that occurs during simulation, determining the number of appropriate simulation hours will always be difficult to determine and regulate. Bradley et al. suggest that “to advance the science, a revisioning of what constitutes clinical learning is needed, to overcome the tension of comparing simulation and traditional experiences. Then, the discipline can embrace the value of clinical learning in all settings and focus on outcomes and quality experiences instead of hours”.

Requirements for Simulation Educators

Twenty BONs had regulations relating to simulation instructor preparation whereas ten BONs did not. Of the 20 states that had regulations the survey revealed a considerable variation in the regulations. Some states were more specific than others referring to specific standards such as INACSL Standards of Best Practice, SimulationSM, or the NCSBN guidelines as the criteria for preparing educators. Many of the BONs simply stated that simulation faculty needed to be trained in the use of simulation. Common themes included the need for documented and focused training, maintaining competencies in simulation and debriefing, and participating in ongoing professional development. Arizona identified the need for educators to be prepared to respond to ‘‘the psychological impact of simulation on students.’’

What Does This Mean?

The survey found considerable variation in simulation education regulations exists between states. Inconsistencies between anecdotal reports and published state guidelines were discovered. The survey suggests that accessibility to state regulations varied between states and this could account for the inconsistencies. Some BON websites were difficult to navigate and methods for dissemination of new regulations were not always clear. Both issues could lead to varying simulation practices within a state and between states. The actual number of required clinical hours varies between states and programs Smiley, (2019) reported the number of clinical hours in prelicensure nursing programs ranged from as low as 270 to as high as 960. If the number of simulation hours is based on a percentage of the total clinical hours, the actual number of simulation hours will vary considerably.

High quality simulation comes from theory based simulation methodologies and debriefing strategies as well as vetted scenarios and well prepared simulation faculty. If BONs do not write appropriate regulations, simulation education in prelicensure programs will be haphazard and remain highly variable. The good news is that even though your BON may not have clear simulation regulations, INACSL has crafted standards and criteria that can guide your program through a standardization process. Do not be overwhelmed by all the standards but as you grow your program keep the standards in mind building your program one step at a time.

Make sure the program director or dean sees the standards so that they understand the steps needed to create a “high quality” simulation program. The bad news is that if you want national accreditation for your simulation program it will cost you. SSH accreditation fee for the core standards and one of the ART standards is $5975.00 plus travel expenses for the accreditors. This may be beyond the budget of small schools particularly Associate Degree Nursing Programs however the INACSL standards are free and they provide an excellent foundation for any simulation program.

Read More About US State Clinical Simulation Regulations for Prelicensure Nursing Programs!


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